One month, Ryan Bayley, MD’08, was practicing emergency medicine with the energy and joy he had experienced for years. The next month, his shifts had become drudgery.

It was the final year of his emergency medicine and EMS fellowship training in New York City. It was the last year of a pathway he had been on for 13 years, starting with several years working as a paramedic, followed by medical school at Vanderbilt, residency and fellowship.

“I was doing exactly what I had envisioned for myself, but I was physically struggling to recover between shifts, and the challenges of daily practice were wearing me down more than I expected,” Bayley recalls.

“I attributed it to residency and fellowship being a pretty long haul and thought that things would improve once I was out on my own.

“And they just didn’t.”

Bayley was suffering from burnout, but he didn’t recognize it.

More than half of the physicians in the United States report symptoms of burnout — a syndrome of exhaustion, emotional detachment from one’s work and reduced sense of personal accomplishment.

“There is a recognition nationally that there is a problem in medicine,” says Reid Thompson, MD, William F. Meacham Professor and Chair of Neurological Surgery. “Whether burnout is a new problem is not clear, but what is clear is that it seems to be on the upswing.”

Vanderbilt University Medical Center (VUMC) has established a task force to address the issue and seek ways to improve physician well-being. Thompson and Mary Yarbrough, MD, MPH, associate professor of Clinical Medicine and executive director of Faculty and Staff Health and Wellness, are co-leading the effort.

“I would argue that the institutions that will be successful going forward will be the ones that have addressed this problem head-on and have developed strategies to mitigate physician burnout,” Thompson says.

The problem of burnout

Although occupational burnout was described in 1974, and a psychological tool for assessing its symptoms was published in 1981, the first large-scale national study of physician wellness in the United States didn’t happen until 2011.

That year, Tait Shanafelt, MD, and colleagues at the Mayo Clinic and the American Medical Association invited about 27,000 U.S. physicians to participate in a survey using the Maslach Burnout Inventory, a 22-item questionnaire that measures the three dimensions of burnout.

They found that among the 7,288 physicians who completed the survey, 45.8 percent reported at least one symptom of burnout. The highest rates occurred in specialties at the front lines of healthcare: emergency medicine, general internal medicine and family medicine.

Burnout was more common in physicians compared to working adults in other fields, and physicians were almost twice as likely as other workers to be dissatisfied with work-life balance.

Three years later, the situation was worse.

Shanafelt and his colleagues conducted another study in 2014 and found that among 6,880 physicians who completed the survey, 54.4 percent reported at least one symptom of burnout, an increase of nearly 10 percent compared to 2011. The percentage of physicians satisfied with work-life balance dropped almost 10 percent. Working adults in other fields had minimal changes in burnout satisfaction with work-life balance.

Other studies have linked physician burnout to higher rates of errors, infection and mortality in hospitalized patients.

“It’s clear that physicians are strained,” Yarbrough says. “The healthcare system and demands on physicians have changed dramatically in recent years.

“We have more pressures, more technology, more documentation, different ways that people are communicating with us, electronic medical records to navigate, quality metrics to meet, patients grading us. The list goes on and on, and there’s a toll for each of these things.”

Documentation requirements have become particularly onerous, says Thompson, with layers upon layers being added and nothing being subtracted.

According to a study published in the September/October 2017 Annals of Family Medicine, primary care physicians spend more than half of their workday interacting with electronic health record systems during and after clinic hours.

“All these things seem to be pulling us away from what brought us to medicine in the first place — the fact that we like taking care of patients,” Thompson says. “More and more, we’re not doing that. We’re spending hours charting things — including late hours at home ‘pajama charting.’ That’s not great.”

A paradigm shift in medicine

At Vanderbilt, the VUMC Task Force for Empowerment and Well-being, led by Yarbrough and Thompson, is tackling the issue of physician wellness. The 16-member multidisciplinary group opted for a name that reflected its desired focus.

“We want to find ways to empower physicians to take control of this issue,” Yarbrough says. “What is it that physicians need in order to find meaning and enjoyment in their work? Our focus is on well-being and prevention.”

The task force asked Vanderbilt physicians to complete an online survey with two questions:

Vanderbilt is not immune to burnout, say task force co-chairs Reid Thompson, MD, and Mary Yarbrough, MD, but there are programs in place to help. Photo by Joe Howell.

“As a physician in the VUMC community, what do you need to do your best work and enhance your personal well-being?”

“If 10 reflects your optimal health and wellness and 0 reflects burnout or significant professional stressors or concerns, where do you place yourself on this scale?”

About half of VUMC physicians rated themselves below 5 on this scale, consistent with national findings on physician burnout.

“We’re not immune from this problem at Vanderbilt,” Thompson says.

The VUMC survey revealed broad themes that physicians identified in naming needs for their best work and personal well-being. The most mentioned needs included self-care, staffing support, leadership support and autonomy.

For its initial recommendations, the task force looked for enhancements that could happen relatively quickly. Some examples: adding wellness to the VUMC Credo, encouraging physicians to see their primary care providers, addressing childcare hours and addressing parking needs for on-call physicians.

Other recommendations will require more study of staffing needs, leadership training on wellness, guidelines for the meaning of time away from work and tracking implementation of changes.

“We’re starting a conversation and calling attention to these needs,” Yarbrough says. “I think we’re in the middle of a paradigm shift in medicine where we’ve got to step back and think about how we structure our practices. What are the things that we really need doctors to do, and what are the things that might better be done in other ways?”

Thompson envisions Vanderbilt leading the way to big changes in efficiency.

“I think the problem boils down to time and how our time gets eaten up by things that pull us away from the things that give meaning to what we do and to our lives,” he says. “The task force is focusing on how we can make physicians’ lives here much more efficient to buy back time for them.”

That might mean adding scribes to the care team or leveraging technology to have an automated system taking notes in the background as physicians see patients.

“How can we invent that here?” Thompson says. “How can we be leaders nationally in developing strategies that empower physicians to get back to what they find joyful in their careers and in their lives?”

“I wondered what was wrong with me.”

Faced with exhaustion and detachment during his final year of training, Bayley did what physicians do — he attempted to diagnose the problem.

He saw his general practitioner to test for endocrine disorders; he visited a sleep specialist; he consulted a psychiatrist.

“Even though I was apparently physically and mentally healthy, I was struggling to feel rested enough to show up at my next shift, and I had lost the sense of connection with patients and colleagues,” Bayley recalls. “I wondered what was wrong with me and why all of the other residents and physicians seemed to be enjoying the work and having no difficulties.”

He continued to suffer, devising ways to avoid the stresses of clinical practice and protect his limited energy, until he happened into an opportunity to work with an executive coach who specialized in burnout and fulfillment.

“The coach had never worked with a physician before, but he was willing and I was desperate.”

Coaching — a structured process of reflection, goal-setting and skills development — made it possible for Bayley to “really step back and be fully conscious and objective about the things that were going on in my life,” he says. “At that point, it became pretty obvious that I was experiencing burnout. I knew the triad of exhaustion, depersonalization and loss of efficacy, and I met those criteria.”

Through mindfulness and other techniques, coaching helped Bayley develop skills to better manage the “inevitable challenges that come with practicing in the current healthcare system,” so that he was able to practice emergency medicine again “and really enjoy the job.”

“When you’re burned out,it’s very easy to start focusing all of your time and efforton avoiding any furtherdepletion.” – Ryan Bayley, MD

He also re-prioritized his health and became more intentional about how he spent his time, particularly with his children, he says.

“I was able to balance my professional life with other areas of my life that had gotten neglected along the way.”

Impressed with the impact coaching had on him, and now recognizing the same symptoms in physicians all around him, Bayley trained as a professional coach and began to coach physicians part-time while continuing to practice emergency medicine.

He now coaches physicians full-time and consults with healthcare institutions on physician well-being and performance. Bayley works with physicians all over the United States, generally by phone or video conference two to four times per month for an average of eight months, although some clients require just a few sessions to work on a very focused challenge.

Coaching creates an objective and safe space for physicians to step back and work on themselves and their well-being, Bayley says. He helps his clients understand what is important to them, what is getting in the way, and how to make changes to reclaim control and satisfaction.

The work has given him insights into his own experience during his final year of training, he says.

“I’ll think back and realize, oh, that behavior was really a manifestation of trying to avoid a difficult thought or feeling about work. When you’re burned out, it’s very easy to start focusing all of your time and effort on avoiding any further depletion. Life becomes about avoidance.”

Take, for example, Bayley’s experience in an emergency department during cold and flu season.

“You can imagine that a doctor has lots of difficult conversations about why a patient doesn’t need antibiotics or doesn’t need to be admitted to the hospital for a cold,” he says. “Then that patient storms out of the ER calling you an idiot. That’s depleting.”

Bayley found himself speeding through exams of the “worried well” and prescribing antibiotics. In the moment, it felt like success: no arguments, no disgruntled patients, high throughput. But longer-term consequences soon kicked in: concerns about antibiotic overuse, not educating patients in a way that empowers them, not practicing good medicine.

“That really is a hallmark of burnout — when you’re tangled in the difficult thoughts and feelings that are a normal part of daily medical practice and you start to spend your time and energy avoiding them, but you do so in ineffective ways,” he says. “You’re in a blind spot where ‘problem-solving’ actually fuels the problem, and eventually one of those actions catches up with you.”

Institutional culture change

The culture of medicine, Bayley argues, contributes to physician burnout.

“There’s a hidden curriculum during medical training — all the behaviors and attitudes of senior physicians that pervade the profession,” he says.

Ideals like service, responsibility, excellence and autonomy can have a dark side as they morph into obligation, being present for work but not fully functioning because of illness or other conditions, perfectionism, work compulsion and isolation.

“All these things together create a culture of people competing with each other to work harder: who gets in earlier, who stays later, who can push themselves the hardest, who’s strong enough not to show any weakness,” Bayley says. “The culture sets up barriers to admitting you need help and to seeking help.”

Changing the culture to promote wellness is possible, Thompson says. He’s done it in his department.

Thompson points to a trophy on the table in his office. It’s a model skull — containing a softball — that is awarded to the winning team of neurosurgeons participating in an annual charity tournament in Central Park. The highly competitive event draws teams from all over the country. Vanderbilt’s Department of Neurological Surgery won the tournament this year.

“We’ve been focusing on wellness with our residents, doing things like this tournament, whitewater rafting and camping, and we’ve achieved national recognition for our efforts,” Thompson says. John Wellons, MD, professor of Neurological Surgery and director of the department’s residency program, was invited to give a presentation about the wellness curriculum at the 2017 meeting of the Society of Neurological Surgeons, which includes program directors and department chairs from every academic medical center in the country.

“I know that you can change the culture if you start talking about well-being, thinking about it, modeling it and holding people accountable,” Thompson says. “If your focus is a culture of well-being, there’s a lot of good that comes from that.”

It might mean that departments have a chief wellness officer and that department meetings include discussion of wellness initiatives, Thompson adds. It could mean that in addition to focusing on clinical work, research and teaching, mentorship of residents and young faculty might include a focus on wellness — a “fourth leg” of mentoring.

“That happens in pockets, but if it happened institution-wide, that would move the dial to the goal of becoming that place where people want to come and where they want to stay.”

Thompson says he’s honored to be part of the VUMC task force and that its work may be the most important of his career.

“The direction that things are heading with this alarming rate of physician burnout makes it critical to develop strategies to mitigate that, to turn it around. I think it will be a lasting contribution.” n

General surgery resident Eric Quintana, MD, his wife, Elissa, and their niece, Ellena. Photo by John Russell.

Eric Quintana, MD, comes from a close and large extended Hispanic family in New Mexico – his paternal great-grandparents had 17 children; and he has three siblings and 30 first cousins. Quintana is the only member of his family to become a doctor, or to graduate from college.

In June 2017, when he became a first-year general surgery resident at Vanderbilt University Medical Center (VUMC), it was the first time he had left New Mexico and his family for an extended period of time. He had left the state only for brief work trips before, so leaving those he loved behind for at least five years of training was a tough decision.

“Family is a very core element to who I am and who my family is,” said Quintana, 38. “My path to medicine has been very long and nontraditional.”

He started medical school at the University of New Mexico (UNM) when he was 33. Two medical school mentors encouraged him to look outside of New Mexico for his residency. “They said ‘you need to go somewhere else, see a new system, and see the way they do things that might be different from the way we do it here. You can always come back to New Mexico where you already know the way we do things, but if you don’t, you can take New Mexico with you.’”

The long path to an MD

Quintana wanted to be a physician from early in his life. His great-great-grandmother was a curandero, a Mexican healer, who used herbs and roots from the field to make potions and salves. He watched as his family physician, James Houle, MD, established relationships with his patients in addition to taking care of their healthcare needs. “When we got sick he knew exactly what to do. I admired the way he could figure out what was wrong with us, but he also knew about what we were doing in school or in sports. He was like part of the family.”

In high school Quintana took advantage of all the gifted classes available to him, then was offered an internship with a community mentor during his sophomore year. He was matched with a Child Life consultant at the University of New Mexico Children’s Hospital and worked there several hours a day for three to four days a week. Shortly after, he was referred to a unique program that allows high school students to earn a high school and nursing degree at the same time.

In 1998, shortly after he graduated from high school, his daughter, Joann, was born, and he soon became her single parent. After practicing in pediatrics, medical-surgical and ICU care, he was offered a job providing wound care at a large rehabilitation facility. He was promoted to assistant director of nursing at the facility, then director of nursing, while he gradually worked on and completed his bachelor’s degree at UNM.

“I wanted to make sure I’d be there for Joann, so I put off going to medical school. I really enjoyed those years. Looking back, I’m really glad I took the time to be there in her life.”

When his daughter started high school, he left the rehab facility and taught nursing at a community college. Going to medical school was still his plan, but he knew he couldn’t do it just yet. “My philosophy was I could take what I had learned, the years of experience I had and my beliefs, and teach a new generation of nurses coming straight out of the gate,” Quintana said.

He supplemented his income by also working as an emergency room nurse at Presbyterian Rust Medical Center for three 12-hour shifts a week. In 2010, he was given the New Mexico Center for Nursing Excellence Award. Now married, Quintana’s wife, Elissa, asked him why he wasn’t in medical school. “I said, ‘I have to pay the mortgage. I have to pay the bills. I have to get Joann back and forth to school and volleyball.’”

Elissa told him that she could take on extra shifts as an emergency room nurse to support their family, and reminded him that Joann would soon be driving, and Quintana decided he’d finally apply to medical schools. First, he had to complete some pre-med courses and take his Medical College Admission Test. He applied to six medical schools, including the University of New Mexico, where he was accepted and began medical school at age 33.

For the first two years of medical school he continued to work at Presbyterian Rust Medical Center as a clinical nurse educator and a relief charge nurse, but during the third year of medical school and its clinical rotations, he had to reduce his work hours. Also during medical school, he and his wife took in 3-year-old Ellena, Quintana’s niece who had been placed in the Colorado foster system. He and Elissa had to undergo a home study and training to be foster parents, and they were given primary custody of Ellena, now 6.

Choosing a specialty

Quintana was leaning toward emergency medicine during medical school, but during a general surgery rotation, he “fell in love” with being inside the operating room. “I love taking care of surgical patients and being able to see a problem and fix it right then and there. You see results in real time.”

He also enjoys learning about his patients during conversations at the bedside. One encounter during his general surgery rotation in medical school reinforced his desire to pursue general surgery.

“I took care of a patient with a large tumor in his stomach. He couldn’t eat or drink. He said all he wanted was to be able to enjoy his grandkids,” he said. Quintana and the surgical team performed a very complex surgery on the man, restoring his ability to eat and drink and giving him back some quality of life. “I saw him during his follow-up visit and he thanked me for giving him time with his grandkids. The ability to give someone back their life and additional time they would have lost is very rewarding to me.”

But while he could finish an emergency medicine residency in three years, he would have to commit to five or six years in general surgery. “I re-approached my wife and said ‘what if I had to do a five- or six-year residency?’ But she’s so supportive, she said, ‘I’d rather you do something you’re going to love for the rest of your life, instead of doing something just to get it done quickly.’ So I switched my focus to general surgery.”

During his fourth year of medical school, he quit work to focus on residency interviews. He had 113 programs on his initial list, and whittled it down to 56. He was invited for 19 interviews and chose 13 to visit.

“I was very excited to get the invitation from Vanderbilt,” he said, adding that his mentors at UNM had told him it would be a great fit. “During my first lunch here with some research residents, it was apparent that Vanderbilt offered a family environment and there was a collegial relationship among residents.”

Quintana spent the afternoon at VUMC with John Stokes, MD, a general surgery resident, who took him to the operating room to observe a surgery. “When we walked into the OR, there were two surgeons at the table. The way the senior surgeon (Christina Bailey, MD) talked to the junior surgeon (Suzie Lee, MD) blew me away. She (Bailey) was very patient and was going through the case (removing part of a colon) methodically and walking the junior surgeon through her thinking. Then Bailey scrubbed out and Stokes scrubbed in with Quintana still observing. “The senior surgeon was so patient. She just walked him through the surgery and I saw his confidence level soar through the roof. They didn’t know who I was or where I was from. This wasn’t a show for me. This level of teaching has to come from a higher (leadership) level.”

He called Elissa from the Nashville airport after his interview and said “I think I’ve found our new home.” He was invited back for Second Look Weekend, observed more surgery and selected Vanderbilt as his No. 1 choice for Match Day.

In 2017, after Match Day, Quintana become a grandfather. Joann gave birth to a daughter, Azaleyah. Preparing to leave New Mexico and his family would be one of the hardest things he’s done in his life.

“Everyone in my huge family is in New Mexico. Leaving my family behind is more than just leaving my daughter and granddaughter and parents. It’s leaving my grandparents, cousins, nieces, nephews — all of whom I’m very involved with. Telling them I was going to be gone five, six, seven years was difficult.”

A new city, a new life

Nashville has been a great choice for his family, Quintana said. Elissa is a night nurse in VUMC’s Emergency Department, and her mother moved to Nashville with them to help care for Ellena.

As Quintana nears the end of his internship year of residency at Vanderbilt, he isn’t sure what the future holds. Interested in surgical critical care and surgical oncology initially, he has also found colorectal surgery appealing and enjoyed his transplant rotation as well. All would require additional training. He said he and Elissa will decide after his training whether to go back to New Mexico, stay in Nashville or go elsewhere.

“I love surgery. When I was a kid I took apart my dad’s drill to figure out how it worked inside. I rebuilt an engine two or three times. If a heater is broken, I take it apart and fix it. I’ve always had a knack of wanting to solve a puzzle, to solve a mystery and fix it with my hands. Being at the operating table is a whole different experience. When you step up there, the world just disappears and you have this immense focus directly on that patient.”

Not so long ago, when patients’ laboratory reports came back to Vanderbilt University Medical Center (VUMC) indicating the possible presence of serious infections, Infection Prevention team members would print out the reports and divvy them up so they could visit the Medical Center’s clinical floors to investigate each case.

“We were printing off hundreds of lab reports each morning and cutting them apart into piles to distribute to each infection preventionist (IP),” said Vicki Brinsko, RN, MSN, who joined the Infection Prevention team in 1986 as the nursing director of Infection Control. “We would then take these piles of cut-up paper inside alphabetized folders with us when we did our rounds.”

An internally developed infection surveillance platform known as VIPER streamlined that process, bypassed the scissors and brought the infection prevention team into the 21st century.

“Instead of cutting up ‘paper dolls,’ we can focus on initiatives that concentrate on preventing patient harm and keeping our patients safe.”

VIPER stands for the Vanderbilt Infection Prevention Electronic Resource. It was first launched in 2008 through a collaboration between HealthIT and the Department of Infection Prevention. When VIPER was developed a decade ago, the team decided there was no data surveillance product on the market that met VUMC’s needs, so they built their own.

VIPER quickly analyzes data and runs algorithms to determine if the data indicates a troubling infection. This triggers the Infection Prevention team, which can then work with clinicians to quickly put any needed infection prevention and patient isolation measures into action.

“VIPER scans through laboratory results for VUMC patients to identify positive cultures for antibiotic-resistant and epidemiologically important organisms, and positive cultures or laboratory tests for reportable, communicable pathogens,” explained Ted Anders, one of VIPER’s original architects.

VIPER integrates clinical data, including vital signs such as temperature and blood pressure, from a patient’s electronic medical record (EMR) with laboratory results. It also includes the patient’s location history — exactly where they’ve been moved within the hospital during their stay. Those cases that match the Centers for Disease Control and Prevention (CDC) criteria for an infection are flagged for the infection preventionists to investigate more closely, including visiting the clinical floor to examine the patient and consulting with the nursing staff. VIPER pulls all the information together in one view for the infection preventionist so they don’t have to search for the data they need to make their assessment.

VIPER also simplifies the regulatory, state, and CDC reporting of HAIs. For example, VIPER generates data the Infection Prevention team then submits to the CDC’s National Healthcare Safety Network (NHSN), a national healthcare-associated infection tracking system. The system also provides data for in-house reporting, including information patient care units use to measure their progress, all the way up to data to support Pillar Goals requested by Medical Center leadership, said Jim Rickwa, an Infection Prevention business intelligence developer.

“VIPER really shows its usefulness when you consider what a hospital is required to do, both internally and externally,” Rickwa said. “Externally, we have to submit information about the hospital to CMS (the Centers for Medicare & Medicaid Services). We also need to submit information to the state for community health reasons, and then we also need to understand how the hospital is doing internally for our own patient safety and hospital management.

“VIPER does a lot of the legwork for an infection preventionist,” Rickwa added. “Any algorithm or rules that a computer can perform, we let the computer bring it all together and make the relationships it can to save the IPs from having to do that. Then they can focus entirely on the clinical aspect of patient safety.”

]]>https://www.mc.vanderbilt.edu/vanderbiltmedicine/digital-detective/feed/0HAIs at a Glancehttps://www.mc.vanderbilt.edu/vanderbiltmedicine/hais-at-a-glance/
https://www.mc.vanderbilt.edu/vanderbiltmedicine/hais-at-a-glance/#respondThu, 01 Mar 2018 16:29:39 +0000https://www.mc.vanderbilt.edu/vanderbiltmedicine/?p=1689Continued]]>Although significant progress has been made in preventing some infection types, there is much more work to be done. On any given day, about one in 25 hospital patients in the United States has at least one healthcare-associated infection (HAI).

The CDC’s annual National and State Healthcare-Associated Infections Progress Report (HAI Progress Report) describes national and state progress in preventing HAIs. Among national acute care hospitals, the most recent report (2014 data, published 2016) found:

Protecting patients from infection is the top priority for Tom Talbot, MD, MPH, and Vicki Brinsko, MSN, RN. Photo by John Russell.

Every day, a team of epidemiologists, infection preventionists and data analysts report to work at Vanderbilt University Medical Center (VUMC) with a mission: to track invisible trails of microscopic clues, dissect data, analyze lab results, pore over patient medical records and ferret out possible hiding places of disease-causing microbes that could lead to dangerous infections.

Sometimes their search leads to surprising locations such as construction zones, which are plentiful on the sprawling medical campus.

Trading a microscope for a protective hardhat, Vicki Brinsko, MSN, RN, director of Infection Prevention, joins a construction crew surrounded by scaffolding and gets to work, with one goal in mind: patient safety.

“We actually do have our own construction hats, and we go on ‘construction rounds’ several times a week,” Brinsko said. “We visit major project sites where you see the huge cranes outside and smaller reconstruction projects where, for example, they’re adding a new doorway. We’re involved in all of it, making sure that these construction teams — whether it’s a contracted construction company or our own facilities management employees — follow the same rules to protect our patients.”

If it seems surprising that infection prevention specialists are involved in construction, it shouldn’t be. The Infection Prevention team at VUMC, which includes six epidemiologists, eight infection preventionists (IPs) and a data analytics team, is involved at every step of construction, from planning to final punch list. They examine issues such as if the proposed system of air handling is suitable, whether materials are easy to disinfect and if construction dust is well contained so it won’t harm patients.

“There are many things that happen at a medical center that you may not directly connect to infection risk and that are not part of any mandated report,” said Chief Hospital Epidemiologist Tom Talbot, MD, MPH. “There is no one out there asking how well we monitor construction projects, but it’s important. Similarly, if a new medical

device is brought into the Medical Center, we have to make sure there is no unintended consequence. We ask how the device is cleaned and if it might spew anything into the air that people could inhale. We focus not just on the institution’s Pillar Goals and ensuring that the reports that everyone sees outside of these walls look good; all of these other things that can potentially cause harm are important, too.”

“We’re fixers”

The role of infection prevention at hospitals and healthcare facilities has been increasing steadily in the United States, especially in the years following World War II as new discoveries in microbiology and immunology led to better understanding and reduction of healthcare-associated infections (HAIs).

In 2014, the Centers for Disease Control and Prevention (CDC) released results from its Healthcare-associated Infection (HAI) Prevalence Survey, and the results were staggering. On any given day, one in 25 hospital patients contracted at least one HAI. In 2011, an estimated 722,000 Americans developed HAIs in U.S. acute care hospitals, and about 75,000 hospital patients with HAIs died during hospital stays. HAIs cost the healthcare system nearly $6.5 billion annually, according to the CDC.

In 2008, Congress mandated that the Centers for Medicare and Medicaid Services (CMS) stop providing payments to hospitals for the treatment of “reasonably preventable” infections acquired by patients during hospitalizations. In 2010, Congress incorporated HAI prevention into the value-based purchasing program of the Affordable Care Act, leading to even greater accountability for healthcare facilities.

Changes in the regulatory landscape that mandate HAI reporting have also raised the importance of detection and response to HAIs. And in the past decade, electronic surveillance systems have enabled infection preventionists to more quickly identify infections and the presence of multi-drug resistant organisms, resulting in improved patient safety and rapid initiation of infection control measures.

The epidemiologists, infection preventionists and data analysts on the Infection Prevention team are part of the Quality, Safety and Risk Prevention (QSRP) office at VUMC so they work closely with other QSRP staff members, as well as other teams throughout the Medical Center campus that directly impact patient care and safety.

“We’re like the CSI (Crime Scene Investigation) for Vanderbilt,” laughed Talbot. “Well, I guess we’re more like a mini-CDC for the hospital. People that go into this field, well, we’re fixers. We want to fix everything, but we also have to realize that we’re not empowered to fix everything. We are the experts that support the people on the front line that can get in there and fix anything that needs to be fixed.”

Talbot and his team are well aware that every infection statistic is much more than a number on a spreadsheet. The number represents an individual — someone’s parent or child — and successful infection prevention saves lives. Not only does the team investigate suspected infections, they also educate medical staff, develop and enforce infection control policies, and measure the effectiveness of ongoing infection control efforts.

They pay attention to the story the data tell and are watchful for any unusual illness that could signal an outbreak or a new type of infection. But they are also closely connected to the much more personal aspect of infection prevention. They check on medical staff members’ patient care practices, participate in medical rounds in patients’ rooms and attend unit meetings so care teams can tell them directly what’s working and what needs more attention.

While there is much about their jobs that can appear routine, there are times when a rapid, but well-thought out, response can contain a potential outbreak, detouring what could have escalated into a health crisis into an isolated incident. Minutes can mean the difference between life and death, especially when it comes to highly contagious and antibiotic-resistant infections. Members of the Infection Prevention team are on call 24 hours a day, seven days a week, and can be consulted by anyone working on the frontline of patient care.

In 2014, when there was a threat of the deadly West Africa Ebola Virus Disease (EVD), the VUMC Infection Prevention team, working in conjunction with the CDC and with several internal VUMC groups, reacted quickly, communicating detailed information to clinicians on how to evaluate patients for Ebola and what to do if Ebola was suspected, including how to isolate patients. The Medical Center ran multidisciplinary drills to teach clinicians how to safely put on, take off and dispose of coveralls, gloves and face shields.

“Each time we have a major event, we learn a lot,” Talbot said. “We’re fairly nimble. We have great support teams and partners, and we have regular event drills to practice our response. We’re a big place, so it’s somewhat like steering an ocean liner, but we do a good job. We also have people on our staff like Bill Schaffner (VUMC’s first Hospital Epidemiologist and frequent national spokesman on infectious diseases), Vicki and myself, who are linked up closely with national experts, so we can see if we need to change anything we’re doing.

“Since I’ve been in this role, there have been a couple of big keystones. There was SARS (severe acute respiratory syndrome) in the early 2000s and the H1N1 pandemic of 2009-2010. We learned a lot from SARS, we did a lot of preparations, and we thought we were ready. Then Ebola shows up, and we had to develop a plan of action for that. What’s worth learning from all of these is that you’ll get hit quickly by things that are not what are expected at all. The ability to adapt is invaluable.”

National Recognition

Sustained success in infection prevention is a big reason VUMC was honored in 2017 as the first hospital system in the nation to receive the Association for Professionals in Infection Control and Epidemiology (APIC) Program of Distinction designation. The designation is the culmination of an intense review by an APIC survey team that observed infection prevention practices at Vanderbilt University Adult Hospital and Monroe Carell Jr. Children’s Hospital at Vanderbilt, as well as numerous off-site locations.

APIC is the leading professional association for infection preventionists in the United States, with more than 15,000 members. APIC’s Program of Distinction designation measures excellence in existing infection prevention policies and procedures and ongoing quality improvement efforts, as well as compliance with federal regulations.

“We’re incredibly honored to be the first institution in the country to receive this designation,” said Talbot. “One of the big things the surveyors cited was that it is not just the Infection Prevention team that contributed to the effectiveness of our infection prevention programs. This achievement validates our institution-wide dedication to patient safety, our collaboration and teamwork, and every individual’s effort in implementing and consistently following best practices to prevent healthcare-associated infections.”

Because VUMC is an American College of Surgeons-verified Level 1 Trauma Center, the Medical Center cares for critically injured individuals — everyone from gunshot victims to those in serious car accidents. VUMC patients also include those with compromised immune systems especially vulnerable to infection, such as patients receiving cancer treatment and organ transplants. This means the numbers of infections can tend to be higher here than other medical centers that don’t serve these complex patients, but that is not a “fall back” excuse, Talbot said.

“When you look across all hospitals, who we take care of is different,” he said. “We do take care of the sickest of the sick patients. We always aim for zero infections, but can we get there? The good thing is that our focus on the prevention of infections is everywhere in our Medical Center, from public reporting to payments. That’s been a really positive part of our culture here at Vanderbilt because it’s really driven resources to the right places to do the right thing and to reduce all preventable harm.”

VUMC’s healthcare-associated infection (HAI) rates overall are trending in a positive direction, Talbot said. For example, from 2009 to 2017 (estimated with six months of data in 2017), central line associated blood stream infections (CLABSI) in the intensive care units (ICU) were reduced by 79 percent, and non-ICU CLABSIs were reduced by 71 percent. From 2010 until 2017, there was an estimated 61 percent increase in the healthcare worker influenza vaccination rate. From 2009 until 2017, there was an estimated 81 percent increase in hand-hygiene compliance.

“The entire VUMC organization demonstrated commitment to actively integrating infection prevention into routine patient care practices,” said Terrie Lee, RN, MS, a member of the APIC Program of Distinction survey team. “We noted that Infection Prevention and Quality have been working collaboratively to address issues in a highly successful manner. There were also obvious forward-thinking, ‘wow!’ moments identified when we reviewed their methods of instrument reprocessing (high-level disinfection and sterilization), as well as the surveillance and data management system, antibiotic stewardship program, and their unit for care of patients with highly infectious diseases.”

Success Story

A spike in surgical site infections among patients who had colorectal surgeries, a population that is already at higher risk for infection due to the nature of the surgeries, spawned a successful infection prevention initiative at VUMC that has since guided the perioperative procedures for other types of surgeries.

A colorectal SSI task force began meeting twice a month to solve the problem. They reviewed scientific literature and examined other institutions’ practices.

Lack of consistency in how surgeries were handled, from before patients went into surgery until they were released home, seemed to be a key factor playing into the increasing infections, said Senior Quality and Patient Safety Advisor Barbara Martin, MBA, RN, who was part of the taskforce.

“It wasn’t that we weren’t doing things right, it was that we weren’t doing things in a standardized fashion,” she added. “If (infection preventionist) Mary DeVault and I both have the same idea about doing something, but we implement it in different ways, then we’re going to have different outcomes.”

A surgical care bundle, or a defined set of practices to improve outcomes, was developed and implemented for colorectal surgeries.

Elements included pre-surgery bowel preparation and oral antibiotics, using chlorhexidine gluconate cleansing wipes before surgery, the replacement of gowns/gloves in the operating room once the bowel is surgically closed, maintaining a set level of oxygenation, controlling glucose levels, and using wound protection after surgery.

“We started this with every case in colorectal in early 2013 and by June 2013, we had proved that it worked,” said Timothy Geiger, MD, director of Colon and Rectal Surgery. “Every member of the team is critical when it comes to preventing infection, and this was a very collaborative effort between administration, infection prevention, nursing, anesthesia and surgery. This is a nice realization of the fact that from the minute a patient hits the clinic door until the minute they’re discharged, every part of that hospital visit affects their outcome.”

Talbot agrees that one of the most significant factors for success when it comes to infection prevention is having a team that understands the value of every action and is willing to be accountable.

“You have to have people that you partner with that will take the ball and run with it,” Talbot said. “We have the knowledge, the guidelines and the expertise, and we can reach out to peers, but if that receiver on the other end isn’t accepting, then it’s not going to happen. You might get a little success, but you’re not going to get sustained success.”

]]>https://www.mc.vanderbilt.edu/vanderbiltmedicine/invisible-threat/feed/0By the Numbershttps://www.mc.vanderbilt.edu/vanderbiltmedicine/by-the-numbers/
https://www.mc.vanderbilt.edu/vanderbiltmedicine/by-the-numbers/#respondThu, 01 Mar 2018 16:26:50 +0000https://www.mc.vanderbilt.edu/vanderbiltmedicine/?p=1685Continued]]>Over the years the Vanderbilt Transplant Center (VTC) has seen tremendous growth in all of its programs.

In 1962, the first cadaveric kidney transplant was performed. As one of the largest and oldest kidney transplant programs in the country, VTC has performed more than 5,600 kidney transplantations since the program’s creation.

In 1985, the center performed its first heart transplant. In 2017, the center celebrated transplanting its 1,000th heart.

The liver program was created in 1990. One of the largest programs in the Southeast, VUMC has performed more than 2,000 liver transplants.

VUMC is home to the second busiest heart transplant program in the country and ranked No. 1 in the Southeast region for volume for its combined adult and pediatric procedures, according to data released by the Organ Procurement and Transplant Network.

The adult liver program is ranked fifth in the country in volume.

The combined adult-pediatric liver transplant program is tied for sixth in volume.

Vanderbilt is credited with the first lung transplant in Tennessee in 1990 and for the Southeast’s first combined heart/lung transplant in 1987.

VUMC recently performed its first pediatric dual heart/kidney transplant in 2016. According to United Network for Organ Sharing data, there have been just 41 heart/kidney transplants in children younger than 18 performed in the United States since 1988.

In 2017, VTC performed its first adult heart/liver transplant joining a few other centers nationwide.

Since its inception, the center has performed more than 9,000 transplants, including: 5,600 kidney or kidney/pancreas; 1,083 heart; 467 lung or heart/lung; and 2,043 liver.

]]>https://www.mc.vanderbilt.edu/vanderbiltmedicine/by-the-numbers/feed/0Building the team beyond surgeonshttps://www.mc.vanderbilt.edu/vanderbiltmedicine/building-the-team-beyond-surgeons/
https://www.mc.vanderbilt.edu/vanderbiltmedicine/building-the-team-beyond-surgeons/#respondThu, 01 Mar 2018 16:25:42 +0000https://www.mc.vanderbilt.edu/vanderbiltmedicine/?p=1683Continued]]>The infrastructure of the Vanderbilt Transplant Center (VTC) allows for an interdisciplinary environment that creates a culture of teamwork and enhanced communication among all members of the transplant service, said Ed Zavala, administrator for VTC.

The complex nature of transplantation requires significant attention to all aspects of transplantation, including business and administrative issues. Vanderbilt’s focus on ancillary transplant personnel has led to three unique training programs — a transplant pharmacist post graduate year 2 (PGY2) residency, a transplant administrator fellowship and a nurse practitioner fellowship.

VTC, in partnership with the Department of Pharmacy, established the PGY2 residency program in 2006. The program is in high demand from pharmacists that desire specialty training.

Vanderbilt continues to be the only center in the country with a transplant administrator fellowship. It was started in 2011. The nurse practitioner training program began in 2017 and offers a one-year fellowship to prepare nurses to provide quality, evidence-based patient care.

VTC also offers multidisciplinary research opportunities that incorporate pharmacists, nurses, nurse practitioners, social workers and dietitians.

“It’s a unique approach,” said Zavala. “It’s not just physician-led or driven by the surgeons. It’s a collaborative effort among the entire team and an integral component in the continued success of the Transplant Center.”

Ahmya Calloway, 13, had end-stage renal failure that impacted her heart function. The Chattanooga, Tennessee, native had been cared for at Monroe Carell Jr. Hospital at Vanderbilt since she was 2 years old.

Medication was the first thing Calloway’s doctors tried, but over time her health declined to the point that she needed hemodialysis. Soon after it was begun, Calloway’s heart began to fail. She needed a new heart and kidney.

In May 2016, the teenager became Vanderbilt’s first pediatric dual heart/kidney transplant recipient. At the time of her transplant, United Network for Organ Sharing data show there had been just 41 heart/kidney transplants in children younger than 18 performed in the United States since 1988.

“It is very rare for children to receive a simultaneous heart and kidney transplant,” said Calloway’s pediatrician Kathy Jabs, MD. “We have had patients who received a heart transplant who needed a kidney later in life, but never at the same time. Ahmya was our first, and she is doing wonderfully.”

Excellence in innovation

The Vanderbilt Transplant Center (VTC) has experienced many “firsts” over the last couple of years. The longest continuously running transplant program in the Southeast, VTC was established nearly 30 years ago as a multidisciplinary, full-service center for transplantation. The center has made significant advances in education and research and dramatically changed the lives of thousands of patients and their families.

At the core of the center’s success is innovation, a key theme of the charter written in 1989. Lauded for outcomes and patient care, the center’s ability to offer state-of-the-art advances continues to be central to its mission — to propel and direct organ transplantation, research, medicine, technology and education into the future while securing its place as the recognized leader and national authority of multi-organ transplantation.

Seth Karp, MD, is the director of the Vanderbilt Transplant Center, one of the largest organ transplant programs in the Southeast. Photo by Joe Howell.

“We have come a long way since the inception of the program and we continue to integrate the newest innovative and technological solutions in our practices to help us care for our patients,” said Seth Karp, MD, H. William Scott Jr. Professor and chair of the Department of Surgery and director of the Vanderbilt Transplant Center. “As we grow, our ability to perform cutting-edge research and technology increases.

“Innovation to me is anything that helps patients that hasn’t been done before. We are poised to continue our efforts to combine emerging science with clinical delivery.”

Not only does the Transplant Center offer the most novel therapies and technology available, it also incorporates patient support services in areas that include psychiatry, ethics, pharmacy, infectious disease, social work, quality of life and return-to-work. These programs have played a critical role in helping move the center forward and served to set it apart from peer institutions.

“We are a center for training and education,” said Ed Zavala, administrator for VTC. “We recognize the value of treating and supporting our patients as a whole person, which goes beyond the actual act of transplantation.

“We know we can save lives; we have the technology and skills to do that. What we also focus on is the quality of a patient’s life after transplant. How can we make their lives better? It starts even before they begin the transplant process and we work with them beyond that to help them gain a normal level of quality of life.”

Ex-vivo perfusion

For decades the miracle of organ donation has relied on an ice cooler to preserve and transport an organ from donor to recipient.

Until now.

Vanderbilt is participating in two separate clinical trials testing novel preservation and transport devices for both hearts and livers. Both studies have the potential to revolutionize transplantation.

The trials will use devices to keep the organs functioning during transport from the donor to the recipient by mimicking the human body. The revolutionary devices continuously perfuse warm, oxygenated,

nutrient-rich blood and nutrition to the organ to optimize function.

“Ex-vivo perfusion is the next big thing in heart transplantation,” said Ashish Shah, MD, director of Heart Transplant and Mechanical Circulatory Support. “The idea is to expand the donor pool. Opening up the criteria for heart donors will do two things: get people transplanted faster because the geographical area has increased with the removal of the time constraints; and secondly, it allows us to create new knowledge in this innovative field of organ reconditioning and resuscitation.”

Currently, surgeons work to transplant a heart within four hours after it has been harvested from the donor’s body. VTC is one of nine centers across the United States to participate in the EXPAND Heart Pivotal Trial using a device by TransMedics called the Organ Care System (OCS). The device has the ability to increase the amount of time that a heart can be maintained outside the body in a condition suitable for transplantation, providing surgeons the opportunity to assess the heart’s function outside the body and allow for resuscitation, which could potentially improve function after removal from the donor.

“What if we could use this platform to repair hearts?” asked Shah, who holds the Alfred Blalock Endowed Directorship in Cardiac Surgery. “When I look at this technology I am inspired by the extraordinary possibilities of what this holds for the future of transplantation.

“At Vanderbilt we ask and try to answer the relevant questions. If you don’t have a group of people who are thinking in those innovative ways or thinking about innovation, you are just doing heart transplants.”

Like the heart, VTC’s liver program will also test a novel therapy using the OrganOx metra® device, which has the capability of preserving the liver for up to 24 hours outside the body, unattainable with standard preservation methods.

Vanderbilt is among 15 centers, and the only institution in Tennessee, enrolling patients in an investigational, randomized and controlled nationwide study.

“I believe perfusion is the future of organ transplantation,” said Sophoclis Alexopoulos, MD, chief of Vanderbilt’s Division of Hepatobiliary Surgery and Liver Transplantation. “This technology has the potential to increase the donor pool as well as maximize recipient outcomes.

“There are so many future possibilities that this kind of technology can bring. The potential to modulate or modify ex-vivo organs, the potential capability of rehabilitating damaged livers for transplantation and the possibility of modulating the immune profile of the livers to facilitate compatibility issues.”

“In pediatrics, we often utilize existing technology, most often designated for much larger patients, and modulate it into therapies that can work for children,” he said. “It’s what we have been doing for years within the field of mechanical support as a bridge to transplantation.

“At Vanderbilt we are fortunate to have one of the largest mechanical support programs in the United States. Our partnership with our adult mechanical support program has been instrumental in maximizing benefits for our patient population.”

While the lack of research and design dollars for new advancements in pediatric heart transplantation continues to be one of the biggest barriers to innovation, Mettler said there is good news on the horizon.

One novel therapy that is showing promise is ABO-incompatible heart transplants. Children’s Hospital performed the state’s first procedure in 2013. It has done five to date. The procedure — reserved for children 2 years old and younger who have not yet developed significant levels of anti-ABO antibodies — helps a transplant recipient tolerate an organ from a donor whose blood type is incompatible.

In the past, children listed as ABO incompatible for heart transplants were at the “bottom of the list” in terms of matching with a donor. But recent outcomes showing improved survival rates have sparked growing interest in the technique and a reallocation strategy for patients who can receive this type of heart transplant.

Mettler said he is buoyed by the prospect of two additional advancements: the creation of a new heart/liver transplant program for patients with congestive hepatopathy and a new device trial for pediatric heart failure patients.

“If you want to talk about where we are pushing the envelope for our kids, we are starting a true heart/liver transplant program for children,” said Mettler. “Roughly 20-30 percent of our congenital heart volume is made up of patients who have a single ventricle physiology and over time leads to congestive hepatopathy.”

The program, the first in the area, will cater to patients with congestive hepatopathy, a backup of blood in the liver, resulting from heart failure. This disorder eventually causes cirrhosis of the liver with some patients requiring a combined heart/liver transplant.

The need for circulatory support devices for small children with advanced heart failure, most of whom will need a heart transplant, is substantial and has been growing over the past decade.

Vanderbilt was the first in Tennessee to implant the Berlin Heart,

a smaller version of left ventricular assist devices (LVADs) used in adults. The life-saving device is the first of its kind for small infants and children and buys patients time until a donor heart can be found. A plastic tube attaches to the heart and major vessels to divert blood briefly from the body to a pumping chamber that rests outside the body. The pump gives the blood a stronger push than the heart can muster to deliver oxygen and nutrients needed by the brain and vital organs to sustain life.

But the need for additional support led to the creation of a continuous flow device that is set to be tested this year. Vanderbilt is one of the 16 sites for the PumpKIN (Pumps for Kids, Infants and Neonates) trial. The pump, the size of a paper clip, is fully implantable and supports the circulation of infants and children with advanced heart failure.

Lifesaving collaboration

The advancements among the various transplant programs at Vanderbilt give Karp pause and he quickly credits the many team members working to progress transplantation, quality of patient care and outcomes. Among those included in his accolades are members of the transplant teams at the VA Tennessee Valley Healthcare System (VA).

“At Vanderbilt we are honored to collaborate with the outstanding physicians at the VA to deliver state-of-the-art care to our nation’s veterans,” said Karp. “We are the only center in the country that offers bone marrow, liver, kidney, heart, and multiple solid organ transplants to VA patients. We are extraordinarily proud of the trust the VA has placed in our clinical programs over many years.”

In 2017, the dual organ heart/kidney transplant using hepatitis C-positive organs for a disease-free patient was a first for VTC. Traditionally organs infected with hepatitis C, the most common blood-borne infection, would only be offered to patients who also have the disease. If the organ was not suitable for that patient population, it would be discarded.

VTC had already demonstrated the ability to transplant and manage both liver and hearts from a hepatitis C-positive donor into a non-positive recipient with successful outcomes due largely to the advances in anti-viral drug therapies that cure hepatitis C (HCV).

It was a concept learned from the VA, said Joseph Awad, MD, chief of transplantation at the VA. He said the ability to transplant hepatitis C organs into a non hepatitis C patient was a game changer for his program in 2016.

“Hepatitis C has been a major issue for the past 20 or so years,” said Awad. “It’s only been in the last three to four years with the availability of great new medications and it has changed everything. The use of these new antiviral drugs is helping to eradicate HCV, extend the lives of patients already transplanted with HCV, reduce the demand for livers and open up transplantation for more people.”

The Nashville VA, home to the largest transplant center in the country, has blazed a trail in the use of telehealth as a way to provide care to its patients from around the country. The opportunity to consult with patients prior to travel to the VA hospital has allowed for more efficient visits as well as the ability for team members to identify patients who are not acceptable transplant candidates, which saves on unnecessary travel and time for the patients.

But one of the greatest innovations, according to Awad and VA colleague and cardiologist Henry Ooi, MD, is the relationship that began decades ago between the two campuses. Both physicians are part of and work closely with the transplant program at Vanderbilt.

Situated adjacent to VUMC, the Nashville VA is one of a few facilities nationwide to provide transplants for veterans. Modeled after VTC, the Nashville VA is also the only comprehensive transplant center in the VA system, providing all of the most common transplants – kidney, heart, liver and stem cell.

“The collaboration between the two entities has been lifesaving for our patients,” said Ooi, medical director of the advanced heart failure and heart transplant program at the VA.

“Much of what we are able to accomplish, we do in concert with Vanderbilt. We are the only VA heart transplant center that offers dual organ transplants. Our survival rates and outcomes are above the national average. Our shared care model, our proximity and relationship with Vanderbilt are all a part of what makes our transplant program successful,” said Ooi.

The longstanding relationship between the two campuses is a source of pride for Karp. He said the collaboration has provided veterans access to the transplant services at Vanderbilt while enriching the educational opportunities for the center’s medical students and fellows.

As an academic medical center, Karp said innovation is present in most every aspect of the transplant center’s programs. A few areas Karp is focused on include: treating kidney transplant patients with significant obesity; liver regeneration research and having a voice in the national debate in liver allocation which could potentially change the way the UNOS distributes livers that would negatively impact patients listed at Vanderbilt and across the Southeast.

“Our goals are to take outstanding care of our patients and help lead advances in transplant practice, training and research,” said Karp. “We are always thinking about ways to improve this field in a significant way. Sometimes that is through treatment options, technology, relationships, research and advocacy, but at the center of all of this is the patient.”